Healthcare Provider Details

I. General information

NPI: 1295784668
Provider Name (Legal Business Name): CRESTVIEW PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 BROOKMEADE DR
CRESTVIEW FL
32539-6029
US

IV. Provider business mailing address

PO BOX 2010
CRESTVIEW FL
32536-8010
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-7466
  • Fax: 850-682-6591
Mailing address:
  • Phone: 850-682-7466
  • Fax: 850-682-6591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0002988
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2988
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA18906
License Number StateFL

VIII. Authorized Official

Name: THOMAS A. MILLER
Title or Position: PRESIDENT
Credential: P.T.
Phone: 850-682-7466